Health Care Process Planning

- Actions that guide the health care provider - Involves the formulation of goals, objectives
in his/her approach to individuals, families and alternative actions to help the clientele
and communities in an attempt to promote - Also involves the following:
good health conditions and cope up with  Identification of all problems and
health problems health issues
 Prioritization of
Health Care Process at the Individual Level concerns/problems/issues in health
 Assessment  Formulations of goals and objectives
 Planning  Recommendation of strategies to
 Implementation address concerns
 Evaluation
Prioritized Goals Treatment Plan
Pain on (R) To decrease Hot moist pack on
Assessment
shoulder pain on (R) (R) shoulder x 20
- Collection of information and relevant data shoulder mins OD (once a
for analysis and interpretation from 8/10- day)
- Identification and prioritization of a health 3/10 in 2
condition weeks
Limitation of To increase AAROM – AROM
motion on ROM (Range (Active Assistive
2 Main Components
(R) of Motion) of Range of Motion –
1. History Taking shoulder all (R) Active Range of
- Subjective information shoulder Motion) on all (R)
Hx (Health Hx) motions by shoulder motions x
30-50 10 reps/set x 3
Health History degrees in 2 sets
weeks

1. Chief complaint (CC)

Implementation
2. Past Medical History (PMedHx)
3. History of Present Illness (HPI)
Technique: Interviewing the client
4. Review of System (ROS)

2. Physical Examination Patient notes

- Objective information
- Or PE/PA (Physical Assessment)
PT NOTES Date: _____
Techniques:
1. Inspection (through eyes) The following PT Mx were given to the patient
2. Palpation (kapa) 1. Hot moist pack on the (R) shoulder for
3. Percussion (Percussion hammer) 20 mins

Muscular/skeletal, respiratory system

- Use of force/sound, hands/tips of
fingers (no usage of instrument)

4. Auscultation (Stethoscope)
 Purpose:
Evaluation  Identify…
- Checking whether the intended results were  Patterns of health and illness
achieved  Risk factors for health problems
- Has 4 Dimensions:  Deviations from normal
 Effectiveness  Available resources for
 Efficiency adaptation
 Appropriateness
 Adequacy Cyanosis – Bluish discoloration of the skin
(+Black & purple)
1. Pain on the (R) shoulder decreased Pale – Pallor decrease of red blood cells
from 8/10 – 3/10 Jaundice – Yellowish
2. ROM of all (R) shoulder motions in
increased by 30 degrees Guidelines in Health History Taking
1. Sources of Information
- Clients family or significant others,
health team members & client’s
Assessment health record
Health History 2. Most of the data are SUBJECTIVE
Steps of Health Assessment 3. Focus on data/information from all the
 Collection of subjective data client’s dimensions
 Collection of objective data 4. Record data using clear, concise and
 Validation of data appropriate terminology
 Documentation of data
*Kapag di nasulat = di ginawa Interview
- Means of collecting objective data
Collecting Data (Subjective & objective)
- Getting a client’s DATABASE Focus of Interview
1. Establishing rapport and a trusting
Collecting Data relationship with the client
DATABASE sources: 2. Gathering information on the client’s
A. Health history developmental, psychological,
B. Physical assessment physiologic, socio-cultural and spiritual
C. Laboratory and diagnostic tests statuses
D. Materials contributed by other health
personnel Phases of the Interview
*Bawal basahin yung flip chart (metal board)  Introductory phase
 Working phase
Health History
 Summary and closing phase
- Gives subjective information on how a
health condition come about
- Data/information to be collected
 Level of wellness
 Changes in life patterns
 Socio-cultural role
 Mental and emotional reactions to
illness
 Other health conditions
Guidelines of an Effective Interview
1. Start by using ice breakers Other Guidelines in History Taking
2. Be observant  Prepare in advance all
3. Ask questions in a mom-threatening way information that should be
4. Let the interview flow naturally gathered
5. Obtain cues about which part of the data  Get an appropriate setting
collected requires in-depth investigation  Assess interviewer’s self before
6. Control the interview hand
 Can interview relatives for
Approaches of Interview reliability
 Directive  Introduce self before interview
 Non-directive  Address patient formally
 Do not challenge the interviewee
1. Directive  Be attentive
- Highly structured
 Clarify unclear matters
- Elicits specific information
 Do not be judgmental and
- Interviewer controls subject matter
overcritical
- Used when time is limited
 Do not preach or dictate
2. Non-directive  Allow time when patient answers
- Interviewer allows patient to control  Record relevant data
the purpose, subject matter & pacing
of the interview Basic Components of the Health History
*Usually in nurses  Demographic data
 Source and reliability of information
 Reasons for seeking care/chief
Types of Interview Questions complaint
CLOSED OPEN-ENDED
- Used in directive - Associated with non-
 History of present illness/Present health
interview (Yes/No) directive interview (not history
answerable by yes/no)  Past medical history/ past health
- Generally requires yes - Specify broad topics to be
 Family history
or no or short factual discovered & write longer  Socio-economic history
answers giving answers
specific information  Functional assessment

NEUTRAL LEADING
- Can be answered by the - Direct the client’s
client without direction or answer
pressure from the
interviewer
- Open-ended - Closed
- Used in non-directive - Used in a directive
interview interview
- Give client less
opportunity whether
the answer is true or
not
- Can create problems
that clients give
inaccurate response
just to please the
health care provider
-
Basic Components of the Health History
 1. Demographic (Biographical) Data
- Client’s data (client’s initial)
- Gender
- Age, birthdate, birthplace
- Mental (civil) status
- Nationality
- Religion
- Address & telephone no.
- Educational background
- Occupation (usual & present)
- Usual source of medical care
- Date of admission
- Diagnosis (clinic)

2. Source and Reliability of information

- Should be in narrative form (describe
specifically according to the patient’s
manifestation or capability)

Ex: The patient was competent to

provide information. She was able to speak
clearly; conscious and coherent: oriented to
time, place and person

3. Reasons for seeking care or chief

complaint (CC)
- Recorded as direct quotes

Ex: “I’m going to college and I need to

get a physical check-up; the college is
requiring me to get a hepatitis B vaccine”

“I need to find a new health care provider to

treat my asthma because it is starting to
bother me a

For an ill person:

HPI or Chronological